NCLEX-PN
NCLEX PN Test Bank
1. In which situation is the nurse upholding the ethical principle of fidelity?
- A. Providing complete information regarding treatment options to a client with newly diagnosed cancer
- B. Allowing a client to decide when to receive daily hygiene care
- C. Inserting a 19-gauge intravenous catheter into a client requiring a blood transfusion
- D. Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan
Correct answer: D
Rationale: Fidelity is the ethical principle of keeping promises made to clients, families, and other healthcare professionals. Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan exemplifies fidelity. By advocating for the client's preferences and ensuring their requests are addressed, the nurse demonstrates a commitment to fulfilling promises made to the client. Allowing a client to decide when to receive daily hygiene care relates to respecting autonomy, not fidelity. Inserting a 19-gauge intravenous catheter into a client needing a blood transfusion aligns with beneficence, as it involves taking action to provide necessary treatment. Providing complete information to a client with newly diagnosed cancer about treatment options reflects justice, promoting fairness and equity in healthcare by offering equal access to information and treatment choices.
2. A nurse discharge planner is preparing a client for discharge from an acute care setting. The nurse assesses that skilled home care services are clinically indicated. This assessment is based on all of the following indicators except:
- A. the client has been admitted to the hospital three times in the last 2 months.
- B. the client has a Foley catheter.
- C. the client's family is available to care for him 24 hours a day.
- D. the client is ordered to continue IV antibiotics 5 days post discharge.
Correct answer: V
Rationale: Family availability to provide care and assistance is not an indicator for skilled home care services. In fact, the nurse might see an opportunity for family education to meet the client's needs so that less community support is needed. This should be discussed and negotiated with the family. Frequent hospital readmissions indicate that the client has not been able to manage either due to condition instability or lack of care needs being met, which is a red flag for home care services to monitor and meet those needs appropriately. A Foley catheter requires home health care due to infection potential and care requirements. IV antibiotics also necessitate home care for maintaining line patency and assessing the site.
3. The client has a new prosthetic hip, and the nurse is repositioning them. Which position should be avoided to prevent injury to the new prosthetic hip?
- A. abduction of the hip
- B. adduction of the hip
- C. flexing the hip at 80� flexion
- D. flexing the hip at 90�
Correct answer: B
Rationale: The correct answer is 'adduction of the hip.' When a client has a new prosthetic hip, adduction (movement of the leg toward the midline of the body) should be avoided to prevent injury to the new prosthetic hip. Abduction (movement of the leg away from the midline) is typically allowed and may even be encouraged. Flexing the hip at certain degrees is acceptable, but adduction should be avoided to prevent complications or dislocation of the prosthetic hip. Therefore, options A, C, and D are incorrect because they do not pose a direct risk to the new prosthetic hip compared to adduction.
4. A nurse discusses staff empowerment with the nursing team. The nurse explains that staff empowerment has which function?
- A. Fosters the growth of others so that they are less dependent on the leader
- B. Means that the staff has the power to reprimand and punish any individual who is not meeting the standards of care delivery
- C. Indicates that the nurse leader will make decisions regarding the nursing unit and expects that the staff will comply with the changes
- D. Allows the staff to make every decision regarding employee scheduling
Correct answer: A
Rationale: Staff empowerment fosters the growth of others and facilitates their development so that they are less dependent on their leader. This empowerment is about enhancing skills and autonomy, not about reprimanding or punishing others (Choice B). Empowerment involves shared decision-making and autonomy, not unilateral decision-making by the leader (Choice C). Moreover, staff empowerment does not mean that staff should make every decision regarding operational aspects like employee scheduling (Choice D). It is primarily focused on developing individuals' capabilities and fostering independence within the team.
5. Once the nurse has made initial rounds and checked all of the assigned clients, which client should be cared for first?
- A. A client who is scheduled for surgery at 1 p.m.
- B. A client in skeletal traction who has just received pain medication
- C. A client scheduled for physical therapy at 11 a.m.
- D. A client who is able to perform activities of daily living independently
Correct answer: A
Rationale: The priority should be given to the client who is scheduled for surgery at 1 p.m. Preparing a client for surgery involves various tasks such as physical and emotional preparation, following healthcare provider instructions, and potential last-minute changes in the surgical schedule. It is crucial to ensure the client is adequately prepared. Providing care to a client who just received pain medication can wait until the medication takes effect. Clients who are independent in performing daily activities and those scheduled for physical therapy later in the morning are not as high a priority as preparing a client for an upcoming surgery. Therefore, the client scheduled for surgery should be cared for first to ensure all necessary preparations are completed.
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